Failure to Provide Adequate Care and Services to Prevent the Development of a New Pressure Sore or Allow an Existing Bedsore to Heal

In a summary statement of deficiencies dated 12/17/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure [a resident at the facility] who had been identified at risk for pressure ulcers received assistance with repositioning.”

The deficient practice was noted by state investigator reviewed a resident’s MDS (Minimum Data Set) indicating that the resident “was at high-risk pressure ulcers due to impaired bed mobility and impaired transfer.” In addition, the MDS (Minimum Data Set) further noted that the resident “had an unstageable stage IV pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g.) tendon, joint capsule. Undermining and sinus tracts also may be associated with Stage IV pressure ulcers).” The MDS (Minimum Data Set) also noted that the resident “required two person assist for transfers and bed mobility and had no behaviors of refusing care.”

A notation was made on 11/25/2015 of the resident’s unstageable ulcer [which is an ulcer with full tissue thickness loss in which the base of the ulcer was covered by slough and eschar and therefore the true depth of the damage cannot be estimated until these are removed].” The resident’s wound measured 2.8 centimeters by 1.4 centimeters by 0.4 centimeters and healing well with no slough noted.”

Seven days later on 12/02/2015, the resident’s unstageable ulcer remained the same in size as the previous week. The following week, the unstageable pressure had decreased in size to a measurement of 2.4 centimeters by 0.6 centimeters by 0.4 centimeters and “was healing well no slough noted.” The following two weeks, the measurement stayed the same except a notation that the wound was now “pink in color.”

However, on 12/16/2015, an observation was made of the resident concerning repositioning. The state investigator noted that “at 1:32 PM [the resident] was placed in her bed [and remain there] for three hours and 45 minutes without being repositioned.”

The investigator reviewed the resident’s Skin Integrity Assessment: Prevention and Treatment Care Plan that instruct the staff “implement an individualized turning schedule in applicable (every) two hours, to lay [the resident] on the left side while in bed but not at all times, in turn [the resident] with two pillows slightly high on side. Wheelchair positioning per Medical Doctor order.”

Our Robbinsdale nursing home neglect attorneys recognize the failing to provide adequate care and services according to physician’s orders when allowing a resident’s bedsore to heal could place their health and well-being in jeopardy. The deficient practice by the nursing staff at Robbinsdale Rehabilitation and Care Center might be considered negligence or mistreatment because their actions failed to follow established procedures and protocols for providing acceptable standards of care.

Failure to Ensure That All Services Provided by the Nursing Facility Meet the Highest Level of Professional Standards of Quality

In a summary statement of deficiencies dated 02/05/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “develop an initial care plan to include smoking safety for [a resident at the facility] who is newly admitted and was observed smoking since admission to the facility.”

The deficient practice was noted by state investigator who conducted a 12:13 PM 02/05/2016 observation of a resident “propelling himself in front of the entrance of the facility […and skidding] to a stop on the sidewalk and dropped a pack of cigarettes on the ground at which time an unidentified individual walking up the sidewalk was noted to assist [the resident] to pick up a cigarette and assist him with a lighter.”

The investigator also reviewed the resident’s 02/02/2015 Admission History and Physical documentation that indicates “he suffered from weakness as well as poor coordination and control of right arm and leg.” The resident’s History and Physical (H & P) further indicated that the resident had a long “history of smoking reported he had been smoking cigarettes. A facility assessment labeled NUR (nurse) Q Shift Post Admit Charting dated 02/05/2015 indicated [the resident] required extensive assist for transfers, was alert to a person only and was at risk for falls.”

The investigator also reviewed the 02/03/2015 Progress Notes that reveal that the resident “was noted by staff walking and wanting to leave the facility. The note further indicated [the resident] was found on the floor inside the front entrance of the facility the same evening while attempting to go outside and smoke a cigarette.”

While the facility’s Progress Notes indicated staff was aware of the resident’s [desire to smoke, and that [the resident] has fallen in the facility, attempting to go outside and smoke, there was no evidence the facility developed and implemented interventions to decrease the risk of falls for [the resident] related to smoking.”

A review of the resident’s 02/04/2016 Care Plan identify the resident “At riskfor falls but did not identify smoking as a causative factor even though [the resident] had fallen while attempting to exit the facility to smoke a cigarette nor do they implement interventions to reduce the risk of falls.

The state investigator conducted a 12:30 PM 02/05/2016 interview with the facility’s ED (Executive Director) stated that the resident “should have a Wanderguard to alert staff if he is attempting to leave the facility to smoke […and stated that the resident] was not in any way, shape or form able to be outside by himself.”

An interview was conducted at 1:10 PM on the same day 02/05/2015 with the facility’s Director of Social Services (DSS) who stated that “the facility was a non-smoking facility and if a resident was identified to be smoking, staff was to take the resident’s cigarettes away and call family. He further stated that if a resident wishes to smoke, they had moved to another facility.” The Director of Social Services also stated: “there were no residents currently in the facility that were deemed unsafe to smoke so safety interventions had not been addressed in regard to the accident prevention related to smoking.”

Our Crystal nursing home neglect attorneys recognize the failing to follow procedures and protocols that meet the highest level of professional standards could place the health and well-being of one or more residents an immediate jeopardy. The deficient practice by the nursing staff at Centennial Gardens for Nursing and Rehabilitation might be considered negligence or mistreatment because their actions failed to follow the facility’s June 2015 policy title: Care Plan Policy and Procedure that reads in part:

“It is the policy of Crystal Care and Rehabilitation Center to provide a temporary Care Plan within 24 hours of admission. The Care Plan would ensure the appropriate care required to maintain or attain the resident the highest level of practical function possible.”

Failure to Make Sure That Every Resident Is Provided the Highest Level of Care to Ensure They Maintain Their Highest Well-Being

In a summary statement of deficiencies dated 06/20/2016, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “provide appropriate care and services including assessment, care plan development and implementation of interventions.” The deficient practice by the nursing staff at Camden Care Center involved one resident “who had non-pressure related skin issues.”

The deficient practice was noted after state investigator observed a resident between 7:05 AM until 8:42 AM on 01/27/2015 of a Certified Nursing Assistant providing morning care to a resident at the facility. After removing the resident’s incontinence brief, the Nursing Assistant washed under the resident’s abdominal fold when the resident replied that it hurt. The Nursing Assistant told the resident “it was a tear under the left abdominal fold, and verified there was no gauze dressing between [the resident] abdominal fold and groin. At 8:09 AM, [a Registered Nurse providing the resident care] arrived to perform wound care.”

The Wound Care Nurse measured wounds on the resident’s left breast, cleansed the wound and applied a dressing. In addition, the Wound Nurse also performed care to the resident’s abdominal slits and noted a 9.2 centimeter long slit in the resident’s left groin.

The state investigator reviewed the resident’s 06/03/2015 Care Plan that revealed that the resident “was at risk for impaired skin integrity.” Notations were also made that interventions “instructed staff to assist [the resident] with repositioning as needed with each check and change […and encourage the resident] to make frequent position changes when [the resident] was able when in a chair or in bed, report skin issues to the physician as they arise and skin checks per facility protocol with bath and as needed.

A review of the resident’s Pressure Ulcer Care Area Assessment indicated that the resident “was a risk for skin breakdown related to incontinence, immobility, decreased sensation related to past stroke and reliance upon staff for repositioning.” The 11/10/2015 Nursing Assistant Assignment Sheet instructed the staff that the resident “required the total assistance of two to check and change before breakfast after lunch in during the night on rounds or as needed and encourage repositioning.”

The investigator also reviewed the resident’s January 2016 TAR (Treatment Administration Record) instructing the staff “to wash and dry abdominal folds and groin, apply 4 x 4 to skinfolds (started 01/20/2015). The treatment was set up for every shift. The information was not on the Care Plan or the Nursing Assistant Assignment Sheet.”

A 9:00 AM 01/27/2015 interview was conducted by the state investigator with the Registered Nurse providing the resident care who stated, “I was not aware of the slits on her abdomen. There are no wound sheets because the wounds developed in December while I was on vacation. The nurse who found the wound should have called the Medical Doctor. I am not a Wound Nurse; the Director is a Wound Nurse. I don’t know if the information is on the weekly sheets. It should be, the nurse should have updated the Care Plan.”

Two hours later at 11:00 AM, second Registered Nurse “was interviewed and stated, ‘I don’t [do] Care Plan turning a repositioning schedules because it is a compliance issue, you cannot get the staff to follow the schedule.”

That same day at 2:31 PM, on 01/27/2015, the Director of Nurses was interviewed and stated that the Nursing Assistant “told me about the slit on [the resident’s] right groin this morning. No one told me about the other wounds or that there was not a treatment for [the medical condition]. The nurse needs to chart on it and tell the Wound Nurse about it. The nurses need to put the appropriate interventions for the open area in place and document. The nurse needs to update the Care Plan. The nurse needs to get a treatment immediately from the doctor.”

In addition, the facility’s Director of Nurses also revealed that “the nurse would follow up weekly and as needed until resolved. I would expect a comprehensive skin assessment to be completed. There should be a tissue tolerance. There should be weekly skin checks for all residents.”

The Director of Nurses also stated that “to determine how often the residents need to be repositioned, we look at the tissue tolerance and comorbidities. Residents need to be turned at baseline, every two hours minimum. If there is a wound, every one hour. If the wound is nasty, the resident should only be up for meals. The individualized turning/repositioning schedule should be on the assignment sheets and Care Plans.

Our Minneapolis nursing home neglect attorneys recognized failing to follow procedures and protocols when providing a level of care to residents could place their health and well-being in jeopardy. The deficient practice by the nursing staff at Camden Care Center might be considered negligence or mistreatment because their actions failed to follow the facility’s 06/20/2005 Policy Title: Skin Care Protocol that reads in part:

Failure to Follow Procedures and Protocols When Investigating and Reporting Any Actual Report of Neglect, Abuse or Mistreatment of Residents

In a summary statement of deficiencies dated 10/29/2015, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “Ensure bruises of an unknown origin were immediately reported to the Administrator and State Agency.” The failure by the nursing staff at Saint Anthony Health Center affected one resident at the facility.

The deficient practice was noted by state investigator reviewed a resident’s MDS (Minimum Data Set) indicating that the resident “had severe cognitive impairment required the extensive assistance of two staff for bed mobility, dressing, locomotion and toileting.”

The investigation involved a 04/20/2015 Incident Report “indicating during evening cares, nursing assistant alerted [a licensed practical nurse on duty] about a bruise to [the resident’s] left in her gluteal area on 04/18/2015.”

At that time, the Licensed Practical Nurse “noted the cause was unknown.” The Registered Nurse on duty “assess the bruise with [another Registered Nurse] on 04/20/2015. The bruise was noted to be 11.0 centimeters by 6.0 centimeters, dark purple in color and located on the inner aspect of the left buttock covering an area near the coccyx and anus.” It was noted that the resident “was unaware of how the bruise occurred.”

The investigation was initiated on 04/20/2015 when the facility’s Executive Director and Director of Nursing were notified of the incident. However, during a 1:28 PM 10/29/2015 interview with the state investigator, the Director of Nursing stated that “she was not sure why they were notified two days later, ‘we report injuries of unknown origin’.”

Our Saint Anthony nursing home abuse attorneys recognized failing to follow procedures and protocols to investigate and report any incident involving an injury of unknown origin could place the health and well-being of the resident in jeopardy. The deficient practice by the nursing staff, administrators and management at Saint Anthony Health Center might be considered negligence or mistreatment because their actions failed to follow the facility’s October 2006 policy title: Vulnerable Adult Abuse Prohibition Policy that reads in part:

“Mandated reporters will immediately report to the Administrator/Executive Director and that the facility shall report immediately to the Common Entry Point.”

Failure to Provide Every Resident a Level of Care That Builds or Maintains Their Dignity and Respect of Individuality

In a summary statement of deficiencies dated 01/30/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure dignified care was provided for [a resident at the facility] who complain staff did not respond to a call light in a timely manner.”

The deficient practice was noted by state surveyor who conducted a review of a resident’s Admission MDS (Minimum Data Set) that identify the resident “had no cognitive impairment, was frequently incontinent of bowel and required extensive assistance from staff from bed mobility, toileting and personal hygiene.”

In addition, the state surveyor reviewed the resident’s 01/13/2015 Care Plan indicating that “the resident had a pressure ulcer, instruct the staff to keep [the resident’s] skin clean, dry and free of body wastes, perspiration and wound drainage, and also to protect the skin from fecal and or urinary incontinence.”

A 6:28 PM 01/26/2015 interview was conducted with the resident and a family member who stated: “several weeks ago an incident happened that upset [the resident].” During the interview, the resident “stated he had and having difficulty with an upset stomach, has some loose stools and couldn’t walk, so the facility suggested wearing an incontinent brief.” The resident also stated that “he had an incontinent bowel movement so he put the call light on to request assistance with changing the soiled brief.”

At that point in the interview, the family member stated that the resident “had been complaining about past long call wait times, so she made a point of watching the clock when [the resident] turn the call light on to see how long it would take for the staff to assist [the resident] with cares.”

The family member stated that “after 50 minutes, no one had come in to help [the resident] so the family member went and raised the concern with [the] Referral Manager [stating that the Referral Manager] took notes and said the situation of [the resident] waiting over 50 minutes for assistance was unacceptable.” The family member also stated that the resident “had a pressure ulcer on his butt, so she was very upset the staff let him lay in stool for so long.” The resident also stated “he couldn’t believe the staff had left him like that and felt, ‘Hopeless’.”

The investigator reviewed the resident’s 01/16/2015 Resident Care Concern Form documenting the event that indicated that the resident “had put the call light on at 2:02PM for assistance with personal hygiene related to an incontinent bowel movement. The nurse entered the room to complete a blood sugar check and a Nursing Assistant entered the room to answer the call light. While both staff or in the room, [the resident] stated he needed assistance and the [Nursing Assistant] stated she would be back after helping another resident.”

However, the Nursing Assistant “never returned to provide [the resident] assistance. The form indicated after the investigation, [the Nursing Assistant] had forgotten to come back to assist [the resident].” The same investigator also noted that “the Administrator reviewed the form and sign the form three days later on 01/19/2015.”

The state investigator conducted an interview at 8:52 AM on 01/29/2015 with the facility’s Corporate Nurse Consultant and Director of Nursing who stated that the resident “sitting in stool for an hour could be a concern of not respecting the resident’s dignity.” In an interview conducted at 10:23 AM the same day on 01/29/2015 with the facility Administrator, the Administrator stated that “the incident involving [the resident] was ‘poor customer service’ and verified a resident should not sit in stool for almost an hour before receiving staff assistance.”

Our Golden Valley nursing home neglect attorneys recognized failing to follow procedures and protocols and a level of care that builds and maintains the dignity and respect of individuality could cause emotional harm to the resident. The deficient practice by the nursing staff at Golden Valley Rehabilitation and Care Center might be considered negligence or mistreatment because the damaging effects of their actions caused by allowing a resident to sit in their own bowel movement for almost an hour without assistance from the nursing staff.

The Consequences of a Poorly Managed Facility

Every day throughout Minneapolis, families entrust the care of an elderly loved one to nursing facilities that pledge to do everything possible to ensure their health and well-being. Unfortunately, residents are often betrayed at the most vulnerable point in their life by the institution in charge of providing them care.

Many nursing facilities are poorly managed or inadequately staffed with poorly trained or unqualified Registered Nurses, Licensed Practical Nurses, Certified Nursing Aides and others employees on the medical team. Without proper oversight, many residents become the victim of abuse, mistreatment or neglect in a variety of ways including:

Bedsores (decubitus ulcer; pressure ulcers; pressure sores)

Sepsis (blood infection) and osteomyelitis (bone infection) due to untreated or undetected open wounds

Dehydration and malnutrition

Medical mistakes including giving the resident medication belonging to another resident, overmedication, under medication or missed dosages

Head injuries, fractures and broken bones caused by falling

Physical, mental and emotional injuries caused by unnecessary or an unauthorized chemical/physical restraint

If you have found signs and symptoms that your loved one has suffered neglect or abuse in a nursing facility, you are probably outraged and heartbroken. In all likelihood, you are left wondering what you can do. Many families will hire an attorney to investigate any and all actions causing your loved one harm and take necessary action to hold the facility and nursing staff accountable for their negligence, abuse or mistreatment.

Hiring a Lawyer

The Minneapolis nursing home abuse attorneys at Nursing Home Law Center LLC have immediate access to all resources necessary to determine whether or not your loved one has received the highest level of care they deserve. Our team of Minnesota elder abuse attorneys will address your concerns and document all pertinent evidence and facts needed to build a case for compensation. Through our actions, we can restore your loved one’s peace, safety and dignity and ensure that they are receiving the highest level of medical care to maximize their well-being at one of the most vulnerable times of their life.

Working as your loved one’s advocate, we take every legal step to ensure others at the facility do not have to experience the same harm in the future. Successful nursing home neglect and abuse cases require careful examination and investigation to determine every cause of harm and injury and the level of responsibility the nursing home and staff had in providing care to your loved one.

We encourage you to contact our Hennepin County elder abuse law offices today at (800) 926-7565 to schedule your free, no obligation full case review. All information you share with our law offices and attorneys remains confidential. We accept all wrongful death lawsuits, personal injury claims and nursing home neglect cases through contingency fee arrangements. This means we provide immediate legal representation, counsel and advice without an upfront fee.

For additional information on Minnesota laws and information on nursing homes look here.

Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa

★★★★★

After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric